www.HIMSSConference.org
#PrecisionHIT
FEBRUARY 11, 2019
ORLANDO, FL
Determining Value of a
Precision Medicine Program
AURORA CANCER CARE
• Sees 1 of every 4 cancer patients in Wisconsin
• More than 8,000 new cancer patients/year
• 25,532 patients served
• 154 oncology physicians (38 Med Onc; 102
Surg Onc; 14 Rad Onc.)
• 19 Med Onc & 11 Rad Onc treatment locations
• 187 Cancer clinical trials
• 1,169 patients on cancer clinical trials
Joined with Advocate to become Advocate Aurora
Health 4/1/18. Collectively see over 16,000
new cancer patients per year.
AURORA CANCER CARE
• Vertically Integrated, Pathways Driven (VIA Oncology),
multidisciplinary Cancer Care System
• 14 weekly video-conferenced disease specific cancer
conferences
• All Medical Oncologists have primary and secondary disease
specific interests
• Large NCORP program to prioritize clinical trials
• Syapse for Molecular Tumor Board and data management
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Why Precision Medicine?
• Precision Medicine presents new challenges for health care
• Genetic data is increasingly used in decision making to determine best treatment
options
• Identifies tumor genetic abnormalities (mutations) to select potential targeted
therapies
• Opens a major new area for treatment of patients with advanced disease
• A Precision Medicine Platform will:
• “Get the data out of the file drawer,” and align EMR, labs and pharmacy information
• Provide decision support for targeted therapies giving better capability to locate, understand, and
act upon molecular data
• A single platform increases efficiency for ordering MDx tests and specialty meds
• Provide automated Clinical Trials matching and more efficient provider communication
• Position our service lines for a Precision Medicine future including: Cardiology, oncology,
neurosciences, orthopedics, women’s health, and behavioral health
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Sequential Therapy Results
With each line of therapy duration of sequential chemotherapy
generally LESS effective compared to prior therapy
Duration of PFS* (Second line Chemo) < 0.8
Duration of PFS (First line Chemo)
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*PFS=Progression free survival
Sequential Therapy Results—Molecular Directed
With each line of therapy duration of sequential therapy
generally MORE effective compared to prior therapy
Duration of PFS (Molecular) > 1.3
Duration of PFS (first line Chemo)
Von Hoff et al, JCO 28(33):4877-4883,2010
Radovich et al. 2016 Oncotarget http://ow.ly/DBXD302mfub
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Molecular Testing
• Requires precertification
• Frequently requires 1-3 weeks for results
• Report can be 25-35 pages
• Physician analysis and discussion with patient can be 2
hours
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Benefits of Cancer Precision Medicine Program
• Lay foundation for precision medicine program in all major service lines
• Attract and retain patients seeking personalized medical care
• Attract and retain professionals in the Precision Medicine category
• With molecular and clinical data on a single platform: Increase our
workflow efficiencies, reduce error, eliminate duplication of tests and
med orders.
• Standardize Clinical Trial data, and easily build cohorts for all service
lines. Much faster determination of eligibility for Pharma trials.
Increase Clinical Trials revenue.
• Molecular Tumor Board can access data and convene virtually for
medical decisions
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Value depends on different perspectives
• Perspective of the Institution
• Perspective of the Patient
• Perspective of the Provider
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Perspective of the Institution
• Legitimate treatment for patients with (potentially) limited options
• Cost of therapy
• Cost of Care
• Expense of PM program
• Reimbursement rate for expensive drugs
• Function of the MTB
• Access to like patient results
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Perspective of the patient
• Looking for legitimate options where none previously offered
• Patients intuitively understand targeted therapy—they have an alteration that
may increase chance of response.
• Wants optimal treatment for cure or prolongation of quality life
• Minimize toxicity and side effects, and financial toxicity of therapy that won’t
work
• They see value in knowing how others have responded--Value of like patients
• Expects Improved result with each drug
• Understanding true costs
• Value of MTB
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Perspective of the provider
• Each successive chemotherapy treatment is generally less
successful
• Molecular Therapy is currently most effective in advanced
disease
• Limited good options for patients with advanced disease
• Value of MTB—provides interpretation, advice and saves time
— Drugs that work
— Avoidance of drugs that don’t work
• Cost of drug
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DAY
0
Day 1166
Swimmers plot of complex patient
PRECISION MEDICINE PROGRAM AND MOLECULAR
TUMOR BOARD
• Started March 2017
• Original estimate was 50 patients in first year
• Passed 50 in July 2017
• Morphed in that ordering/precerts now done by MTB staff
• Assessment of tissue being studied
• All reports fully reviewed and interpreted for Oncologists
• Patients seen only if requested by treating oncologist
• Full discussion if actionable result
• MTB opinion returned to treating oncologist with recommendations
The Molecular Tumor Board--Weekly
Medical Oncologist—Director
Pharm.D—Co-Director
Molecular Pathologist
Genetic Counselor
Clinical Trials Nurse
Medical Oncologists
Radiation Oncologist
Surgical Oncologist
Others
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Molecular Tumor Board
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Stage IV Lung Adenocarcinoma: BRAF mutation
carboplatin & pemetrexed
chemotherapy
BRAF V600
mutation
dabrafenib & trametinib
anti-BRAF
$24,854/ Month AWP
0 2 4 6 8 10 12 14 16
Months
Since
Diagnosis
Stable disease per imaging
since month 9
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Stage IV Head and Neck Squamous Cell Carcinoma
cisplatin, fluorouracil,
& cetuximab
chemotherapy & anti-EGFR
carboplatin &
paclitaxel
chemotherapy
nivolumab
Anti-PD-1 immunotherapy
$15,330/month
0 5 10 15 20 30
Months
Since
Diagnosis
25
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Stage IV Lung Adenocarcinoma:
TMB High, PD-L1 positive; EGFR, ALK, ROS1 Negative
rituximab
anti-CD20
Lobectomy
2005 2010 2015
nivolumab
Anti-PD-1 immunotherapy
$15,330/month
2016 2017 2018 2019
Full Molecular Panel:
FGFR2 fusion
Stage I NSCLC
Follicular
lymphoma
Metastasis, lung primary
carboplatin, paclitaxel,
& bevacizumab
chemotherapy & anti-VEGF
Re-accumulation of the
pleural effusion
bevacizumab
anti-VEGF
$11,475 q3wk
New
supraclavicular
node
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Genetic Testing Referrals
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Monthly AWP cost of therapy
Drug Name
Disease
Molecular
Monthly/Cycle Cost
Aftatinib
NSCLC
Anti EGFR
$9,785
Cetuximab
Colon, Head and Neck,
NSCLC, Skin
Anti EGFR
$15,994
Vemurafenib
Melanoma
BRAF
+ Cobimetinib
Melanoma
MEK
Inhibitor
$20,557
Panitumumab
Colon
Anti
EGFR
$17,088
Erlotinib
NSCLC
Anti EGFR
$10,141
Dabrafenib
Melanoma
BRAF
+ Trametinib
NSCLC
MEK
Inhibitor
$24,854
Nivolumab
Multiple
Anti PD
-L-1
$15,330
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“NO MARGIN, NO MISSION”
• Sister Irene Kraus
• CEO, Daughters of Charity National Health System
There is value in our precision Medicine program
• Patient’s Perspective
• All potential avenues of therapy explored
• Access to many clinical trials
• Very comfortable with review of molecular data and recommendations
• Understand that their Oncologist’s advice reinforced by large group
• Like patient comparison may avoid less helpful treatment
• Centralization of ordering/precertification reduces risk of large balance
bill
• Some patients more comfortable electing palliative/hospice care
knowing options fully explored
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There is value in our precision Medicine program
• Provider’s Perspective
• Value of consultation from Molecular Tumor Board
• Tremendous time saving allows more productive clinic time (MTB frees about
2 hrs per case)
• Like patient analysis helpful in selecting drugs and also avoiding drugs
• Marked increase in clinical trials referrals
• Better able to counsel patients
• Precertifications help to reassure patients regarding finances
• Molecular platform improves ease of understanding
• Increased referrals to the Hereditary Cancer Prevention and Management
Center (HCPMC)
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There is value in our precision Medicine program
• Institution’s Perspective
• Harder to document value in terms of $$
• Definitely increases biopsies
• Attracts new stage 4 patients
• Offers new therapy not previously available
• Increased referrals to Genetic Counselors and HCPMC which helps
family as well as the patient—may improve cancer prevention
• Syapse platform helps identify clinical trials, similar patient matching for
+/- responders
• Increase in clinical trials referrals
• MTB and appropriate staff critical to success of program
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Thank You!
Special Thanks to:
• Michael A. Thompson, MD, Ph.D., FASCO
• Jennifer Godden, Pharm.D.
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www.HIMSSConference.org
#PrecisionHIT
James L. Weese, MD, FACS
Aurora Cancer Care, Advocate Aurora Health
@JimW9200
